Provider Demographics
NPI:1477916500
Name:BENVIE, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BENVIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:FISKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:228 COLUMBIA RD
Mailing Address - Street 2:D3
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339
Mailing Address - Country:US
Mailing Address - Phone:617-479-0500
Mailing Address - Fax:617-302-2144
Practice Address - Street 1:228 COLUMBIA RD
Practice Address - Street 2:D3
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339
Practice Address - Country:US
Practice Address - Phone:617-479-0500
Practice Address - Fax:617-302-2144
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3098133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered